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Two primary insurances

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kbolt:
What do you do when a patient has two primary insurances and the physician is contracted with both? I have a patient who has a group health plan and an individual policy that does not coordinate with other plans. Do I have to enter both discounts or just one? How will I process this payment? PLEASE HELP!!!

Tracy:
The patient shouldn't have 2 primary. If they have a group plan through their work, then they wouldn't qualify for an indivdual plan that they purchased privatly(and why would you have one?) It sounds like the patient had private insurance and then qualified at their work for group and didn't cancel or let the individual plan know about the group plan. This is a problem for the patient. I would call the individual plan and let them know that the patient has a group plan

kbolt:
I have talked to both insurance companies. The group plan states that they are primary and the individual plan would be secondary. When I call the other insurance with the individual plan, they tell me that the patient has a plan that does not coordinate with other insurances and the refund would go to the patient. But I'm still at a loss on which adjustments I should enter. I believe it is crazy if I have to enter both adjustments, b/c the patient would end up making more than us! At the same time, if I dont enter both would that be violating contracts? I do not understand either why the patient would have this, but I do know that it is possible but rare.

Michele:
Hi,
   The patient may have a private plan that they pay for themselves that pays even if there is other insurance (like AFLAC).  The services are being paid for twice but it is ok.  You should bill both insurances, accept the payment from the group plan as the provider agrees to by participating.  Then take any patient responsibility (copay or coinsurance) from the private plan and refund the patient anything over that.  I know it seems strange but I have seen it on occasion.

Just when you think you've seen it all! 

Michele

kbolt:
First let me tell you thanks for trying to help me but I am still lost. I now understand that the overpmt will definitely go to the patient, but the amt of refund is still in question. Am I required to enter in both provider discounts from both insurances OR do I just enter one provider discount then both payments? This is a major concern, considering the discount amounts will go into affect when determing the amount to refund the patient. Also, in some cases, if I apply both discounts the patient could possibly receive a significant amount of more money than us!

This is way too confusing for me!

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